CHICAGO – A full 45% of all peripherally inserted central catheter lines placed in the basilic or cephalic veins migrated 24 hours after insertion in a retrospective analysis of 100 consecutive lines placed in a neonatal intensive care unit.
Of the 76 peripherally inserted central catheter (PICC) lines placed in the basilic vein, 35.5% migrated inferiorly and medially (mean 1.48 cm), 14.5% migrated laterally (mean 1.74 cm), and 50% did not change position.
Of the 19 PICC lines placed in the cephalic vein, 21% migrated inferiorly and medially (mean 1.36 cm), 15.7% migrated laterally (mean 1.75 cm), and 63.3% did not change position.
None of the five PICC lines placed in the saphenous veins migrated, lead author Dr. Ansel Tjin-A-Tam reported at the annual meeting of the Midwest Society for Pediatric Research.
"We’re not sure why they migrated," he said.
In light of the findings and the potential for catheter migration to result in neonatal death due to cardiac tamponade, he recommended that all neonates have x-rays repeated at 24 hours post-insertion and PICC lines adjusted accordingly.
The chart review involved 100 consecutively placed PICC lines in the NICU at Mount Sinai Hospital in Chicago from January 2010 to March 31. All PICC lines were placed by two certified NICU nurses. X-rays were obtained immediately after insertion and 24 hours post-insertion, and reviewed by a single board-certified pediatric radiologist. The position of the arm was adducted and internally rotated at the shoulder and extended at the elbow on all the x-rays, explained Dr. Tjin-A-Tam, a third-year resident at the hospital.
A recent literature review of studies evaluating the best method to confirm PICC placement in neonates, identified a paucity of information on the subject and the importance of arm position when performing radiographs because movement of the arm can cause migration of the catheter (Neonatal Netw. 2010;29:23-35). The authors suggest supplementing supine chest radiographs with contrast or ultrasound when the line tip position is unclear, and that supine and lateral abdominal radiographs are useful to ensure placement in the inferior vena cava when placing a PICC in the saphenous vein of a neonate.
Dr. Tjin-A-Tam said all of the patients in the study were supine at the time of the radiograph, and agreed that ultrasound could be useful during placement, particularly given concerns for radiation exposure in neonates.
In the current analysis, the neonates’ average birth weight was 1,266 grams (range 420-3,795 g), and the mean dwell time of the PICC lines was 30 days (range 1-45 days).
A recently published review found that 164 (14%) of 1,148 PICC insertions in a NICU had to be replaced due to blockage or migration, and that those exchanged by using the old PICC as a guide wire were associated with a significantly higher risk of central line-associated blood stream infections, compared with those inserted into a new site (9.8% vs. 1%). This association remained significant even after adjusting for confounders (Am. J. Perinatol. 2011;28:419-24).
Dr. Tjin-A-Tam said he was unaware of any infections during the study period.
"If the radiologist shows that it has migrated, they don’t replace the whole PICC line, they just adjust it," he said. "If there is an infection, obviously you have to take the line out."
Dr. Tjin-A-Tam and his coauthors reported no relevant financial disclosures.